who: global health and aging
TRANSCRIPT
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National Institute on AgingNational Institutes of HealthU.S. Department of Health and Human Services
Global Heal t h and Aging
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2 Global Health and Aginghoto credits front cover, left to right (reamstime.com) jembe; ergey alushko; aurin inder; ndianeye;
Magomed Magomedagaev; and Antonella86.
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Preface
Overview
Humanitys Aging
Living Longer
New Disease Patterns
Longer Lives and Disability
New Data on Aging and Health
Assessing the Cost of Aging and Health Care
Health and Work
Changing Role of the Family
Suggested Resources
Contents
ose Maria i
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Preface
The world is facing a situation without precedent: e soon will have more older people than
children and more people at extreme old age than ever before. As both the proportion of olderpeople and the length of life increase throughout the world key questions arise. ill population
aging be accompanied by a longer period of good health a sustained sense of well-being and
extended periods of social engagement and productivity or will it be associated with more illness
disability and dependency? ow will aging affect health care and social costs? Are these futures
inevitable or can we act to establish a physical and social infrastructure that might foster better
health and wellbeing in older age? ow will population aging play out differently for low-income
countries that will age faster than their counterparts have but before they become industrialized
and wealthy?
This brief report attempts to address some of these questions. Above all it emphasizes the central
role that health will play moving forward. A better understanding of the changing relationshipbetween health with age is crucial if we are to create a future that takes full advantage of the
powerful resource inherent in older populations. To do so nations must develop appropriate
data systems and research capacity to monitor andunderstand these patterns and relationships
VSHFLFDOO\ORQJLWXGLQDOVWXGLHVWKDWLQFRUSRUDWHPHDVXUHVRIKHDOWKHFRQRPLFVWDWXVIDPLO\DQG
well-being. And research needs to be better coordinated if we are to discover the most cost-effective
ways to maintain healthful life styles and everyday functioning in countries at different stages of
economic development and with varying resources. lobal efforts are required to understand and
QGFXUHVRUZD\VWRSUHYHQWVXFKDJHUHODWHGGLVHDVHVDV$O]KHLPHUVDQGIUDLOW\DQGWRLPSOHPHQW
existing knowledge about the prevention and treatment of heart disease stroke diabetes and
cancer.
anaging population aging also requires building needed infrastructure and institutions as soon as
possible. The longer we delay the more costly and less effective the solutions are likely to be.
opulation aging is a powerful and transforming demographic force. e are only just beginning
to comprehend its impacts at the national and global levels. As we prepare for a new demographic
reality we hope this report raises awareness not only about the critical link between global health
and aging but also about the importance of rigorous and coordinated research to close gaps in our
knowledge and the need for action based on evidence-based policies.
ichard uzman h
Director, Division of Behavioral and Social Research
National nstitute on Aging
National nstitutes of ealth
1
ohn Beard BB h
Director, Department of Ageing and Life Course
orld ealth rganization
Preface
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2 Global Health and Aging
Figure 1.
Young Children and Older People as a Percentage of Global
Population: 1950-2050
ource nited ations. World Population Prospects: The 2010 Revision.
Available at http//esa.un.org/unpd/wpp.
Overview
The world is on the brink of a demographic
milestone. ince the beginning of recordedhistory young children have outnumbered
WKHLUHOGHUV,QDERXWYH\HDUVWLPHKRZHYHU
the number of people aged 65 or older will
outnumber children under age 5. riven by
falling fertility rates and remarkable increases in
life expectancy population aging will continue
even accelerate (Figure 1). The number of
people aged 65 or older is projected to grow
from an estimated 524 million in 21 to nearly
1.5 billion in 25 with most of the increase in
developing countries.
The remarkable improvements in life
expectancy over the past century were part
of a shift in the leading causes of disease
and death. At the dawn of the 2th century
the major health threats were infectious and
parasitic diseases that most often claimedthe lives of infants and children. Currently
noncommunicable diseases that more commonly
affect adults and older people impose the
greatest burden on global health.
,QWRGD\VGHYHORSLQJFRXQWULHVWKHULVHRI
chronic noncommunicable diseases such as
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changes in lifestyle and diet as well as aging.
The potential economic and societal costs of
noncommunicable diseases of this type risesharply with age and have the ability to affect
economic growth. A orld ealth rganization
analysis in 23 low- and middle-income countries
estimated the economic losses from three
noncommunicable diseases (heart disease
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stroke and diabetes) in these countries would
total 83 billion between 26 and 215.
educing severe disability from disease
and health conditions is one key to holding
down health and social costs. The healthand economic burden of disability also can
be reinforced or alleviated by environmental
characteristics that can determine whether
an older person can remain independent
despite physical limitations. The longer people
can remain mobile and care for themselves
the lower are the costs for long-term care to
families and society.
Because many adult and older-age healthproblems were rooted in early life experiences
and living conditions ensuring good child
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n the meantime generations of children
and young adults who grew up in poverty
and ill health in developing countries will be
entering old age in coming decades potentially
increasing the health burden of older
populations in those countries.
ith continuing declines in death rates among
older people the proportion aged 8 or older
is rising quickly and more people are living
past 1. The limits to life expectancy and
lifespan are not as obvious as once thought.
And there is mounting evidence from cross-national data thatwith appropriate policies
and programspeople can remain healthy
and independent well into old age and can
continue to contribute to their communities
and families.
The potential for an active healthy old age
is tempered by one of the most daunting and
potentially costly consequences of ever-longer
life expectancies: the increase in people withGHPHQWLDHVSHFLDOO\$O]KHLPHUVGLVHDVH0RVW
dementia patients eventually need constant
care and help with the most basic activities
of daily living creating a heavy economic and
social burden. revalence of dementia rises
sharply with age. An estimated 25-3 percent
of people aged 85 or older have dementia.
nless new and more effective interventions
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disease prevalence is expected to rise
dramatically with the aging of the population
in the nited tates and worldwide.
Aging is taking place alongside other broad
social trends that will affect the lives of older
people. conomies are globalizing people are
more likely to live in cities and technology
is evolving rapidly. emographic and family
changes mean there will be fewer older people
with families to care for them. eople today
have fewer children are less likely to bemarried and are less likely to live with older
generations. ith declining support from
families society will need better information
and tools to ensure the well-being of the
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Overview
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4 Global Health and Aging
Humanitys Aging
n 21 an estimated 524 million people were
DJHGRUROGHUSHUFHQWRI WKHZRUOGV
population. By 25 this number is expected to
nearly triple to about 1.5 billion representing
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more developed countries have the oldest
SRSXODWLRQSUROHVWKHYDVWPDMRULW\RI
older peopleand the most rapidly aging
populationsare in less developed countries.
Between 21 and 25 the number of older
people in less developed countries is projected to
increase more than 25 percent compared with
a 71 percent increase in developed countries.
This remarkable phenomenon is being driven
by declines in fertility and improvements in
longevity. ith fewer children entering the
population and people living longer older
people are making up an increasing share of the
total population. n more developed countries
fertility fell below the replacement rate of two
live births per woman by the 197s down from
nearly three children per woman around 195.
ven more crucial for population aging fertility
fell with surprising speed in many less developed
countries from an average of six children in
195 to an average of two or three children
in 25. n 26 fertility was at or below the
two-child replacement level in 44 less developed
countries.
ost developed nations have had decades to
adjust to their changing age structures. t took
PRUHWKDQ\HDUVIRUWKHVKDUHRI UDQFHV
population aged 65 or older to rise from 7percent to 14 percent. n contrast many less
developed countries are experiencing a rapid
increase in the number and percentage of older
people often within a single generation (Figure
2). or example the same demographic aging
that unfolded over more than a century in
rance will occur in just two decades in Brazil.
eveloping countries will need to adapt quickly
to this new reality. any less developed nations
Figure 2.The Speed of Population Aging
Time required or expected for percentage of population aged 65 and over to
rise from 7 percent to 14 percent
ource insella , e .An Aging World: 2008. ashington, C ational nstitute on Aging
and .. Census Bureau, 2009.
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ZLOOQHHGQHZSROLFLHVWKDWHQVXUHWKHQDQFLDO
security of older people and that provide the
health and social care they need without the
same extended period of economic growth
experienced by aging societies in the est.
n other words some countries may grow oldbefore they grow rich.
n some countries the sheer number of
people entering older ages will challenge
national infrastructures particularly health
systems. This numeric surge in older people is
GUDPDWLFDOO\LOOXVWUDWHGLQWKHZRUOGVWZRPRVW
populous countries: China and ndia (Figure 3).
&KLQDVROGHUSRSXODWLRQWKRVHRYHUDJH
will likely swell to 33 million by 25 from 11PLOOLRQWRGD\,QGLDVFXUUHQWROGHUSRSXODWLRQ
of 6 million is projected to exceed 227 million
in 25 an increase of nearly 28 percent from
today. By the middle of this century there
could be 1 million Chinese over the age of 8.
This is an amazing achievement considering
that there were fewer than 14 million people
this age on the entire planet just a century ago.
Figure 3.
Growth of the Population Aged 65 and Older in India and China:
2010-2050
Source: United Nations. World Population Prospects: The 2010 Revision.
Available at: http://esa.un.org/unpd/wpp.
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6 Global Health and Aging
Living Longer
The dramatic increase in average life expectancy
during the 2th century ranks as one ofVRFLHW\VJUHDWHVWDFKLHYHPHQWV$OWKRXJKPRVW
babies born in 19 did not live past age 5 life
expectancy at birth now exceeds 83 years in
apanthe current leaderand is at least 81
years in several other countries. ess developed
regions of the world have experienced a steady
increase in life expectancy since orld ar
although not all regions have shared in
these improvements. (ne notable exception
is the fall in life expectancy in many parts of
Africa because of deaths caused by the /
A epidemic.) The most dramatic and rapid
gains have occurred in ast Asia where life
expectancy at birth increased from less than 45
years in 195 to more than 74 years today.
These improvements are part of a major
transition in human health spreading around
the globe at different rates and along different
pathways. This transition encompasses a
broad set of changes that include a declinefrom high to low fertility; a steady increase
in life expectancy at birth and at older ages;
and a shift in the leading causes of death and
illness from infectious and parasitic diseases
to noncommunicable diseases and chronic
conditions. n early nonindustrial societies the
risk of death was high at every age and only a
small proportion of people reached old age. n
modern societies most people live past middle
age and deaths are highly concentrated at older
ages.
The victories against infectious and parasitic
diseases are a triumph for public health
projects of the 2th century which immunized
millions of people against smallpox polio
and major childhood killers like measles. ven
earlier better living standards especially
more nutritious diets and cleaner drinking
water began to reduce serious infections and
prevent deaths among children. ore childrenwere surviving their vulnerable early years
and reaching adulthood. n fact more than
6 percent of the improvement in female life
expectancy at birth in developed countries
between 185 and 19 occurred because more
children were living to age 15 not because more
DGXOWVZHUHUHDFKLQJROGDJH,WZDVQWXQWLO
the 2th century that mortality rates began
to decline within the older ages. esearch for
more recent periods shows a surprising and
continuing improvement in life expectancy
among those aged 8 or above.
The progressive increase in survival in these
oldest age groups was not anticipated by
demographers and it raises questions about how
high the average life expectancy can realistically
rise and about the potential length of the human
lifespan. hile some experts assume that life
expectancy must be approaching an upper limitBernaNamoglu|Dreamstime.com
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Figure 4.Female Life Expectancy in Developed Countries: 1840-2009
ource ighest reported life expectancy for the years 840 to 2000 from online supplementary
material to eppen , aupel . Broken limits to life expectancy. Science 2002; 296029-
0. All other data points from the uman Mortality atabase (http//www.mortality.org)
provided by oland au (niversity of ostock). Additional discussion can be found in
Christensen , oblhammer , au , aupel . Aging populations The challenges ahead.
The Lancet2009; 74/969696-208.
Living Longer
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8 Global Health and Aging
data on life expectancies between 184 and 27
show a steady increase averaging about three
months of life per year. The country with the
highest average life expectancy has varied over
time (Figure 4). n 184 it was weden and
today it is apanbut the pattern is strikinglysimilar. o far there is little evidence that life
expectancy has stopped rising even in apan.
The rising life expectancy within the older
population itself is increasing the number and
proportion of people at very old ages. The
oldest old (people aged 85 or older) constitute
SHUFHQWRI WKHZRUOGVDQGRYHUSRSXODWLRQ
12 percent in more developed countries and 6
percent in less developed countries. n manycountries the oldest old are now the fastest
growing part of the total population. n a
Figure 5.
Percentage Change in the Worlds Population by Age: 2010-2050
ource nited ations, World Population Prospects: The 2010 Revision.
Available at http//esa.un.org/unpd/wpp.
global level the 85-and-over population is
projected to increase 351 percent between 21
and 25 compared to a 188 percent increase for
the population aged 65 or older and a 22 percent
increase for the population under age 65 (Figure 5).
The global number of centenarians is projected
to increase 1-fold between 21 and 25. n
the mid-199s some researchers estimated that
over the course of human history the odds of
living from birth to age 1 may have risen from
1 in 2 to 1 in 5 for females in low-
mortality nations such as apan and weden.
KLVJURXSVORQJHYLW\PD\LQFUHDVHHYHQIDVWHU
than current projections assumeprevious
population projections often underestimated
decreases in mortality rates among the oldest
old.
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9
The transition from high to low mortality
and fertility that accompanied socioeconomicdevelopment has also meant a shift in
the leading causes of disease and death.
emographers and epidemiologists describe this
shift as part of an epidemiologic transition
characterized by the waning of infectious and
acute diseases and the emerging importance of
chronic and degenerative diseases. igh death
rates from infectious diseases are commonly
associated with the poverty poor diets and
limited infrastructure found in developing
countries. Although many developing countries
still experience high child mortality from
infectious and parasitic diseases one of the
major epidemiologic trends of the current
century is the rise of chronic and degenerativediseases in countries throughout the world
regardless of income level.
vidence from the multicountry lobal Burden
of isease project and other international
epidemiologic research shows that health
problems associated with wealthy and aged
populations affect a wide and expanding
swath of world population. ver the next
1 to 15 years people in every world region
will suffer more death and disability fromsuch noncommunicable diseases as heart
disease cancer and diabetes than from
Figure 6.The Increasing Burden of Chronic Noncommunicable Diseases:
2008 and 2030
ource orld ealth rganization,Projections of Mortality and Burden of Disease, 2004-2030.
Available at http//www.who.int/healthinfo/global_burden_disease/projections/en/index.html.
New Disease Patterns
New Disease Patterns
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10 Global Health and Aging
$JURZLQJERG\RI UHVHDUFKQGVWKDWPDQ\
health problems in adulthood and old age stem
from infections and health conditions early in life.
ome researchers argue that important aspects ofadult health are determined before birth and that
nourishment in utero and during infancy has a
direct bearing on the development of risk factors for
adult diseasesespecially cardiovascular diseases.
arly malnutrition in atin America is highly
correlated with self-reported diabetes for example
and childhood rheumatic fever is a frequent cause of
adult heart disease in developing countries.
esearch also shows that delayed physical growth inchildhood reduces physical and cognitive functioning
LQODWHU\HDUV'DWDRQ&KLQDVROGHVWROGVKRZWKDW
rarely or never suffering from serious illnesses or
receiving adequate medical care during childhood
results in a much lower risk of suffering cognitive
impairments or physical limitations at ages 8 or
older.
roving links between childhood health conditions
and adult development and health is a complicatedresearch challenge. esearchers rarely have the data
necessary to separate the health effects of changes
in living standards or environmental conditions
GXULQJDSHUVRQVOLIHIURPKHDOWKHIIHFWVUHODWHG
to his or her birth or childhood diseases. owever
a wedish study with excellent historical data
concluded that reduced early exposure to infectious
diseases was related to increases in life expectancy.
A cross-national investigation of data from two
surveys of older populations in atin America
and the Caribbean also found links between earlyconditions and later disability. The older people in
the studies were born and grew up during times
of generally poor nutrition and higher risk of
exposure to infectious diseases. n the uerto ican
survey the probability of being disabled was more
than 64 percent higher for people growing up in
Lasting Importance of Childinfectious and parasitic diseases. The myththat noncommunicable diseases affect mainly
DIXHQWDQGDJHGSRSXODWLRQVZDVGLVSHOOHGE\
the project which combines information about
mortality and morbidity from every world region
WRDVVHVVWKHWRWDOKHDOWKEXUGHQIURPVSHFLFdiseases. The burden is measured by estimating the
ORVVRI KHDOWK\\HDUVRI OLIHGXHWRDVSHFLFFDXVH
based on detailed epidemiological information. n
28 noncommunicable diseases accounted for an
estimated 86 percent of the burden of disease in
high-income countries 65 percent in middle-income
countries and a surprising 37 percent in low-income
countries.
By 23 noncommunicable diseases are projected
to account for more than one-half of the disease
burden in low-income countries and more than
three-fourths in middle-income countries.
nfectious and parasitic diseases will account for
3 percent and 1 percent respectively in low- and
middle-income countries (Figure 6). Among the
6-and-over population noncommunicable diseases
already account for more than 87 percent of the
burden in low- middle- and high-income countries.
But the continuing health threats fromcommunicable diseases for older people cannot
be dismissed either. lder people account for a
growing share of the infectious disease burden in
low-income countries. nfectious disease programs
including those for /A often neglect
older people and ignore the potential effects of
population aging. et antiretroviral therapy is
enabling more people with /A to survive
to older ages. And there is growing evidence
that older people are particularly susceptible
to infectious diseases for a variety of reasons
including immunosenescence (the progressive
deterioration of immune function with age)
and frailty. lder people already suffering from
one chronic or infectious disease are especially
vulnerable to additional infectious diseases. or
example type 2 diabetes and tuberculosis are well-
known comorbid risk factors that have serious
health consequences for older people.
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poor conditions than for people growing up in good
conditions. A survey of seven urban centers in atin
America and the Caribbean found the probability
of disability was 43 percent higher for those fromdisadvantaged backgrounds than for those from more
favorable ones (Figure 7).
f these links between early life and health at older
ages can be established more directly they may have
HVSHFLDOO\VLJQLFDQWLPSOLFDWLRQVIRUOHVVGHYHORSHG
countries. eople now growing old in low- and middle-
income countries are likely to have experienced more
ood Health
Figure 7.
Probability of Being Disabled among Elderly in Seven Cities of Latin
America and the Caribbean (2000) and Puerto Rico (2002-2003) by Early Life
Conditions
ource Monteverde M, orohna , alloni A. 2009. ffect of early conditions on disability among the
elderly in atin-America and the Caribbean.Population Studies 2009;6/ 2-.
distress and disadvantage as children than their
counterparts in the developed world and studies
such as those described above suggest that they are
at much greater risk of health problems in older ageoften from multiple noncommunicable diseases.
Behavior and exposure to health risks during a
SHUVRQVDGXOWOLIHDOVRLQXHQFHKHDOWKLQROGHUDJH
xposure to toxic substances at work or at home
arduous physical work smoking alcohol consumption
diet and physical activity may have long-term health
implications.
New Disease Patterns
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12 Global Health and Aging
Are we living healthier as well as longer lives or
are our additional years spent in poor health?There is considerable debate about this question
among researchers and the answers have broad
implications for the growing number of older
people around the world. ne way to examine
the question is to look at changes in rates of
disability one measure of health and function.
ome researchers think there will be a decrease
in the prevalence of disability as life expectancy
increases termed a compression of morbidity.
thers see an expansion of morbidityanincrease in the prevalence of disability as life
expectancy increases. et others argue that as
advances in medicine slow the progression from
chronic disease to disability severe disability
will lessen but milder chronic diseases will
increase. n the nited tates between 1982
and 21 severe disability fell about 25 percent
among those aged 65 or older even as life
expectancy increased. This very positive trend
suggests that we can affect not only how long
we live but also how well we can function withadvancing age. nfortunately this trend may
not continue in part because of rising obesity
among those now entering older ages.
e have less information about disability in
middle- and lower-income countries. ith the
rapid growth of older populations throughout
the worldand the high costs of managing
people with disabilitiescontinuing and better
assessment of trends in disability in different
countries will help researchers discover moreabout why there are such differences across
countries.
ome new international longitudinal research
designed to compare health across countries
promises to provide new insights moving
forward. A 26 analysis sponsored by the ..
National nstitute on Aging (NA) part ofthe .. National nstitutes of ealth found
surprising health differences for example
between non-ispanic whites aged 55 to 64
in the nited tates and ngland. n general
people in higher socioeconomic levels have better
health but the study found that older adults in
the nited tates were less healthy than their
British counterparts at all socioeconomic levels.
The health differences among these young
older people were much greater than the gapsin life expectancy between the two countries.
Because the analysis was limited to non-
+LVSDQLFZKLWHVWKHGLIIHUHQFHVGLGQRWUHHFW
the generally lower health status of blacks or
atinos. The analysis also found that differences
in education and behavioral risk factors (such as
smoking obesity and alcohol use) explained few
of the health differences.
This analysis subsequently included comparable
NA-funded surveys in 1 other uropeancountries and was expanded to adults aged 5 to
KHQGLQJVZHUHVLPLODU$PHULFDQDGXOWV
reported worse health than did uropean adults
as indicated by the presence of chronic diseases
and by measures of disability (Figure 8). At all
levels of wealth Americans were less healthy
than their uropean counterparts. Analyses of
the same data sources also showed that cognitive
functioning declined further between ages 55 and
65 in countries where workers left the labor forceat early ages suggesting that engagement in
work might help preserve cognitive functioning.
ubsequent analyses of these and other studies
should shed more light on these national
differences and similarities and should help guide
SROLFLHVWRDGGUHVVWKHSUREOHPVLGHQWLHG
Longer Lives and Disability
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ource Adapted from Avendano M, lymour MM, Banks , Mackenbach . ealth disadvan-
tage in adults aged 0 to 74 years A comparison of the health of rich and poor Americans
with that of uropeans.American Journal of Public Health2009; 99/40-48, using data from
the ealth and etirement tudy, the nglish ongitudinal tudy of Ageing, and the urvey of
ealth, Ageing and etirement in urope. lease see original source for additional information.
Figure 8.Prevalence of Chronic Disease and Disability among Men and
Women Aged 50-74 Years in the United States, England, and Europe:
2004
Longer Lives and Disability
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14 Global Health and Aging
The Burden of Dementia
The cause of most dementia is unknown but the
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memory reasoning speech and other cognitive
functions. The risk of dementia increases sharplywith age and unless new strategies for prevention
and management are developed this syndrome
is expected to place growing demands on health
DQGORQJWHUPFDUHSURYLGHUVDVWKHZRUOGV
population ages. ementia prevalence estimates
vary considerably internationally in part
because diagnoses and reporting systems are not
standardized. The disease is not easy to diagnose
especially in its early stages. The memory
problems misunderstandings and behaviorcommon in the early and intermediate stages
are often attributed to normal effects of aging
accepted as personality traits or simply ignored.
any cases remain undiagnosed even in the
intermediate more serious stages. A cross-national
assessment conducted by the rganization for
conomic Cooperation and evelopment (C)
estimated that dementia affected about 1 million
people in C member countries around 2
just under 7 percent of people aged 65 or older.
$O]KHLPHUVGLVHDVH$'LVWKHPRVWFRPPRQ
form of dementia and accounted for between
WZRIWKVDQGIRXUIWKVRI DOOGHPHQWLDFDVHV
cited in the C report. ore recent analyses
have estimated the worldwide number of people
living with A/dementia at between 27 million
and 36 million. The prevalence of A and other
dementias is very low at younger ages then nearly
GRXEOHVZLWKHYHU\YH\HDUVRI DJHDIWHUDJH
65. n the C review for example dementiaaffected fewer than 3 percent of those aged 65 to
69 but almost 3 percent of those aged 85 to 89.
ore than one-half of women aged 9 or older
had dementia in rance and ermany as did
about 4 percent in the nited tates and just
under 3 percent in pain.
The projected costs of caring for the growing
numbers of people with dementia are daunting.
KHRUOG$O]KHLPHUHSRUWE\$O]KHLPHUV
isease nternational estimates that the total
worldwide cost of dementia exceeded 6
billion in 21 including informal care provided
by family and others social care provided by
community care professionals and direct costs of
medical care. amily members often play a key
caregiving role especially in the initial stages of
what is typically a slow decline. Ten years ago.. researchers estimated that the annual cost
of informal caregiving for dementia in the nited
tates was 18 billion.
The complexity of the disease and the wide
YDULHW\RI OLYLQJDUUDQJHPHQWVFDQEHGLIFXOWIRU
people and families dealing with dementia and
FRXQWULHVPXVWFRSHZLWKWKHPRXQWLQJQDQFLDO
and social impact. The challenge is even greater
in the less developed world where an estimatedtwo-thirds or more of dementia sufferers live
but where few coping resources are available.
URMHFWLRQVE\$O]KHLPHUV'LVHDVH,QWHUQDWLRQDO
suggest that 115 million people worldwide will
be living with A/dementia in 25 with a
markedly increasing proportion of this total in
less developed countries(Figure 9). lobal efforts
DUHXQGHUZD\WRXQGHUVWDQGDQGQGFXUHVRU
ways of preventing such age-related diseases as
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ViestursKalvans|Dreamstime.com
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ource Alzheimers isease nternational, World Alzheimer Report, 2010. Available at
KWWSZZZDO]FRXNUHVHDUFKOHV:RUOG$O]KHLPHU5HSRUWSGI
Figure 9.
The Growth of Numbers of People with Dementia in High- income
Countries and Low- and Middle-income Countries: 2010-2050
Longer Lives and Disability
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16 Global Health and Aging
The transition from high to low mortality and
fertilityand the shift from communicable tononcommunicable diseasesoccurred fairly
recently in much of the world. till according
to the orld ealth rganization () most
countries have been slow to generate and use
evidence to develop an effective health response
to new disease patterns and aging populations.
n light of this the organization mounted a
multicountry longitudinal study designed to
simultaneously generate data raise awareness of
the health issues of older people and inform public
policies.
The tudy on lobal Ageing and Adult
ealth (A) involves nationally representative
cohorts of respondents aged 5 and over in six
countries (China hana ndia exico ussia
and outh Africa) who will be followed as they age.A cohort of respondents aged 18 to 49 also will be
followed over time in each country for comparison.
KHUVWZDYHRI $*GDWDFROOHFWLRQ
has been completed with future waves planned for
212 and 214.
n addition to myriad demographic and
socioeconomic characteristics the study collects
data on risk factors health exams and biomarkers.
Biomarkers such as blood pressure and pulse rate
height and weight hip and waist circumferenceDQGEORRGVSRWVIURPQJHUSULFVDUHYDOXDEOH
and objective measures that improve the precision
of self-reported health in the survey. A also
collects data on grip strength and lung capacity
New Data on Aging and Health
Figure 10.Overall Health Status Score in Six Countries for Males and Females:
Circa 2009
otes ealth score ranges from 0 (worst health) to 00 (best health) and is a composite measure
derived from 6 functioning questions using item response theory. ational data collections con-
ducted during the period 2007-200.
ource Tabulations provided by the orld ealth rganization Multi-Country tudies nit,
eneva, based on data from the tudy on global Aing and adult health (A).
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17
Figure 11.
Percentage of Adults with Three or More Major Risk Factors: Circa 2009
otes Major risk factors include physical inactivity, current tobacco use, heavy alcohol consump-
tion, a high-risk waist-hip ratio, hypertension, and obesity. ational data collections conducted
during the period 2007-200.
ource Tabulations provided by the orld ealth rganization Multi-Country tudies nit,
eneva, based on data from the tudy on global Aing and adult health (A).
60%
50%
40%
30%
20%
10%
0%
18-49 50-59 60-69 70-79 80+
Age Group
and administers tests of cognition vision and
mobility to produce objective indicators of
UHVSRQGHQWVKHDOWKDQGDELOLW\WRFDUU\RXWEDVLF
activities of daily living. As additional waves
RI GDWDDUHFROOHFWHGGXULQJWKHVHUHVSRQGHQWV
later years the study will seek to monitor healthLQWHUYHQWLRQVDQGDGGUHVVFKDQJHVLQUHVSRQGHQWV
well-being.
A primary objective of A is to obtain reliable
and valid data that allow for international
comparisons. esearchers derive a composite
measure from responses to 16 questions about
health and physical limitations. This health score
ranges from (worst health) to 1 (best health)
and is shown for men and women in each of the six
A countries in Figure 10. n each country the
health status score declines with age as expected.
And at each age in each country the score for males
is higher than for females. omen live longer than
men on average but have poorer health status.
The number of disabled people in most developing
countries seems certain to increase as the number
of older people continues to rise. ealth systems
need better data to understand the health risks
faced by older people and to target appropriate
prevention and intervention services. TheA data show that the percentage of people
with at least three of six health risk factors
(physical inactivity current tobacco use heavy
alcohol consumption a high-risk waist-hip
ratio hypertension or obesity) rises with
age but the patterns and the percentages
vary by country (Figure 11).QHRI $*V
important contributions will be to assess
KRZWKHVHULVIDFWRUSUROHVDIIHFWFXUUHQW
and future disability. maller family size anddeclining prevalence of co-residence by multiple
generations likely will introduce further
challenges for families in developing countries in
caring for older relatives.
New Data on Aging and Health
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18 Global Health and Aging
RSXODWLRQDJLQJLVOLNHO\WRLQXHQFHSDWWHUQV
of health care spending in both developed and
developing countries in the decades to come.
n developed countries where acute care and
institutional long-term care services are widely
available the use of medical care services by
adults rises with age and per capita expenditures
on health care are relatively high among older age
groups. Accordingly the rising proportion of older
people is placing upward pressure on overall health
care spending in the developed world although
other factors such as income growth and advances
in the technological capabilities of medicine
generally play a much larger role.
elatively little is known about aging and
health care costs in the developing world. Many
developing nations are just now establishing
baseline estimates of the prevalence and incidence
of various diseases and conditions. ,QLWLDOQGLQJV
from the A project which provides data
on blood pressure among women in six developing
countries show an upward trend by age in the
percentage of women with moderate or severe
hypertension (see Figure 12) although the patterns
DQGDJHVSHFLFOHYHOVRI K\SHUWHQVLRQYDU\DPRQJ
the countries. f rising hypertension rates in
those populations are not adequately addressed
the resulting high rates of cerebrovascular and
Assessing the Costs of Agingand Health Care
Figure 12.
Percentage of Women with Moderate or Severe Hypertension in Six
Countries: Circa 2009
ote ational data collections conducted during the period 2007-200.
ource Tabulations provided by the orld ealth rganization Multi-Country tudies nit,
eneva, based on data from the tudy on global Aing and adult health (A).
50%
40%
30%
20%
10%
0%
18-49 50-59 60-69 70-79 80+
Age Group
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19
cardiovascular disease are likely to require costly
medical treatments that might have been avoided
with antihypertensive therapies costing just a
few cents per day per patient. arly detection
and effective management of risk factors such as
hypertensionand other important conditionssuch as diabetes which can greatly complicate the
treatment of cardiovascular diseasein developing
countries can be inexpensive and effective ways of
controlling future health care costs. An important
future payoff for data collection projects such as
A will be the ability to link changes in health
status with health expenditures and other relevant
variables for individuals and households. This will
provide crucial evidence for policymakers designing
health interventions.
A large proportion of health care costs associated
with advancing age are incurred in the year or so
before death. As more people survive to increasingly
older ages the high cost of prolonging life is shifted
to ever-older ages. n many societies the nature
and extent of medical treatment at very old agesis a contentious issue. owever data from the
nited tates suggest that health care spending at
the end of life is not increasing any more rapidly
than health care spending in general. At the same
time governments and international organizations
are stressing the need for cost-of-illness studies on
age-related diseases in part to anticipate the likely
burden of increasingly prevalent and expensive
FKURQLFFRQGLWLRQV$O]KHLPHUVGLVHDVHLQ
particular. Also needed are studies of comparativeperformance or comparative effectiveness in
low-income countries of various treatments and
interventions.
The Costs of Cardiovascular Disease and Cancer
n high-income countries heart disease stroke
and cancer have long been the leading contributors
to the overall disease burden. The burden fromthese and other chronic and noncommunicable
diseases is increasing in middle- and low-income
countries as well (igure 6).
To gauge the economic impact of shifting disease
SUROHVLQGHYHORSLQJFRXQWULHVWKHRUOG+HDOWK
rganization () estimated the loss of
economic output associated with chronic disease in
23 low- and middle-income nations which together
account for about 80 percent of the total chronic
disease mortality in the developing world.
The analysis focused on a subset of leading
chronic diseases: heart disease stroke and
diabetes. n 2006 this subset of diseases incurred
estimated economic losses ranging from 20
million to 30 million in ietnam and thiopia
and up to nearly 1 billion in China and ndia.
hort-term projections (to 2015) indicate that
losses will nearly double in most of the countries
if no preventive actions are taken. The potential
estimated loss in economic output for the 23
nations as a whole between 2006 and 2015 totaled
84 billion.
A recent analysis of global cancer trends by the
conomist ntelligence nit () estimated that
there were 13 million new cancer cases in 2009. The
cost associated with these new cases was at least
286 billion. These costs could escalate because
of the silent epidemic of cancer in less well-off
resource-scarce regions as people live longer and
adopt estern diets and lifestyles. The
analysis estimated that less developed countries
accounted for 61 percent of the new cases in 2009.
argely because of global aging the incidence
of cancer is expected to accelerate in coming
decades. The annual number of new cancer cases
is projected to rise to 17 million by 2020 and reach
27 million by 2030. A growing proportion of the
global total will be found in the less developed
ZRUOGDQGE\DOPRVWKDOI RI WKHZRUOGVQHZ
cases will occur in Asia.
Assessing the Costs of Aging and Health Care
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20 Global Health and Aging
Health and Work
n the developed world older people often
leave the formal workforce in their later years
although they may continue to contribute to
society in many ways including participating
in the informal workforce volunteering or
providing crucial help for their families. There
is no physiologic reason that many older people
cannot participate in the formal workforce but
the expectation that people will cease working
when they reach a certain age has gained
credence over the past century. ising incomes
along with public and private pension systems
have allowed people to retire based on their agerather than any health-related problem.
t is ironic that the age at retirement from the
workforce has been dropping at the same time
that life expectancy has been increasing. lder
people today spend many years in retirement.
n C countries in 27 the average man
left the labor force before age 64 and could
expect 18 years of retirement (Figure 13). The
average woman stopped working at age 63
and looked forward to more than 22 years of
retirement if they adopt similar concepts of
retirement.
any high-income countries now want people
to work for more years to slow escalating
costs of pensions and health care for retirees
especially given smaller cohorts entering the
labor force. ost middle- and low-income
countries will face similar challenges.
ther than the economic incentives of
pensions what would make people stay in the
workforce longer? To start misconceptions
about older workers abound and perceptions
may need to change. n addition to having
acquired more knowledge and job skills
through experience than younger workers
most older adults show intact learning and
thinking although there are some declines in
cognitive function most notably in the speed
of information processing. oreover there is
some evidence that staying in the labor force
after age 55 is associated with slower loss ofcognitive function perhaps because of the
stimulation of the workplace and related social
engagement.
ven physical abilities may not deteriorate
as quickly as commonly assumed. Although
relatively little is known about the relationship
between age and productivity (which takes
wages into account) one study of erman
assembly line workers in an automotive plant
IRXQGWKDWWKHDYHUDJHDJHSURGXFWLYLW\SUROH
of workers increased until age 65.
hether older people spend more years in
the labor market also will depend on the
types of jobs available to them. any jobs in
industrialized countries do not require physical
H[HUWLRQWKDWPLJKWEHGLIFXOWIRUDQROGHU
worker but they may necessitate acquiring
new skills and retraining to adjust to changing
work environments. vidence is needed on thecapacity of older workers especially those with
ORZHGXFDWLRQOHYHOVWRSURWIURPUHWUDLQLQJ
lder people with limited mobility or other
KHDOWKSUREOHPVPD\UHXLUHPRUHH[LEOH
schedules or adapted work environments.
Considerations may need to be given to the
value of building new approaches at work or
institutions that will increase the ease with
which older people can contribute outside of
their families.JosefMuellek|Dreamstime.com
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21
Figure 13.
Expected Years of Retirement for Men in Selected OECD Countries: 2007
ote C average is for 0 C member nations.
ource rganization for conomic Cooperation and evelopment. OECD Society at a Glance
2009. Available at http//public.tableausoftware.com/views/etirement/A.
Health and Work
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22 Global Health and Aging
amilial support and caregiving among
generations typically run in both directions.lder people often provide care for a variety
of others (spouses older parents children
grandchildren and nonfamily members) while
families and especially adult children are the
primary source of support and care for their
older relatives. ost older people today have
children and many have grandchildren and
living siblings. owever in countries with very
low birth rates future generations will have few
if any siblings. The global trend toward havingfewer children assures that there will be less
potential care and support for older people from
their families in the future.
As life expectancy increases in most nations so
do the odds that several generations are alive at
the same time. n more developed countries this
is manifested as a beanpole family a vertical
extension of family structure characterized
by more but smaller generations. As mortality
rates continue to improve more people in their
5s and 6s are likely to have surviving parents
aunts and uncles. Consequently more children
will know their grandparents and even their
great-grandparents especially their great-
grandmothers. There is no historical precedent
for a majority of middle-aged and older adults
having living parents.
owever while the number of surviving
generations in a family may have increasedtoday these generations are more likely to live
separately. n many countries the shape of
WKHIDPLO\XQLWUHHFWVFKDQJLQJVRFLDOQRUPV
economic security; rising rates of migration
divorce and remarriage; and blended and
stepfamily relations. n addition more adults
are choosing not to marry or have children at
all. n parts of sub-aharan Africa the skipped-
generation family householdin which an
older person or couple resides with at least one
grandchild but no middle-generation familymembershas become increasingly common
because of high mortality from /A.
n ambia for example 3 percent of older
women head such households. n developed
countries couples and single mothers often
delay childbearing until their 3s and 4s
households increasingly have both adults
working and more children are being raised in
single-parent households.
The number and often the percentage of older
people living alone is rising in most countries.
n some uropean countries more than 4
percent of women aged 65 or older live alone.
ven in societies with strong traditions of older
parents living with children such as in apan
traditional living arrangements are becoming
less common (Figure 14).
n the past living alone in older age often
was equated with social isolation or familyabandonment. owever research in many
cultural settings shows that older people prefer
to be in their own homes and communities
even if that means living alone. This preference
is reinforced by greater longevity expanded
VRFLDOEHQHWVLQFUHDVHGKRPHRZQHUVKLSHOGHU
friendly housing and an emphasis in many
nations on community care.
The ultimate impact of these changing family
patterns on health is unknown. lder people
ZKROLYHDORQHDUHOHVVOLHO\WREHQHWIURP
sharing goods that might be available in a larger
family and the risk of falling into poverty in
older age may increase as family size falls. n
the other hand older people are also a resource
for younger generations and their absence may
create an additional burden for younger family
members.
Changing Role of the Family
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23
Long-Term Careany of the oldest-old lose their ability to live
independently because of limited mobility
frailty or other declines in physical or cognitive
functioning. any require some form of long-
term care which can include home nursing
community care and assisted living residential
FDUHDQGORQJVWD\KRVSLWDOVKHVLJQLFDQW
costs associated with providing this support
may need to be borne by families and society.
n less developed countries that do not havean established and affordable long-term care
infrastructure this cost may take the form
of other family members withdrawing from
employment or school to care for older relatives.
And as more developing country residents seek
jobs in cities or other areas their older relatives
back home will have less access to informal
family care.
The future need for long-term care services
(both formal and informal) will largely be
determined by changes in the absolute number
of people in the oldest age groups coupled with
trends in disability rates. iven the increases in
life expectancy and the sheer numeric growth
of older populations demographic momentum
will likely raise the demand for care. This
growth could however be alleviated by declines
in disability among older people. urther thenarrowing gap between female and male life
expectancy reduces widowhood and could mean
a higher potential supply of informal care by
older spouses. The great opportunity for public
KHDOWKSURJUDPVLQWKHUVWKDOI RI WKHVW
century is to keep older people healthy longer
delaying or avoiding disability and dependence.
Figure 14.
Living Arrangements of People Aged 65 and Over in Japan: 1960 to 2005
1RWH3HUFHQWDJHVOLYLQJZLWKFKLOGUHQLQFOXGHVPDOOQXPEHUVRISHRSOHOLYLQJLQXQVSHFLHG
arrangements.
ources apan ational nstitute of opulation and ocial ecurity esearch.Population
Statistics of Japan 2008.
Available at http//www.ipss.go.jp/p-info/e/psj2008/2008-07.xls.
Changing Role of the Family
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24 Global Health and Aging
KHQGLQJVKLJKOLJKWHGWKURXJKRXWWKLV
booklet underscore the value of cross-national
data for research and policy. nternational
and multi-country data help governments and
policymakers better understand the broader
implications and consequences of aging
learn from the experiences in other countries
including those with different health care
systems and at a different point along the aging
and development continuum and facilitate the
crafting of appropriate policies especially in the
developing world.
aluable new information is coming fromnationally representative surveys often panel
studies that follow the same group of people
as they age. The .. ealth and etirement
tudy () begun in 199 has painted a
GHWDLOHGSLFWXUHRI ROGHUDGXOWVKHDOWKZRU
retirement income and wealth and family
characteristics and intergenerational transfers.
n recent years other nations have used the
+DELHQQLDOVXUYH\RI PRUHWKDQ
$PHULFDQVRYHUDJHDVDPRGHOIRUSODQQLQJ
similar large-scale longitudinal studies
of their own populations. everal parallel
studies have been established throughout the
world including in China ngland ndia
reland apan orea and exico with more
planned in other countries such as Thailand
and Brazil. n addition coordinated multi-
country panel studies are effectively building
an infrastructure of comprehensive and
comparable data on households and individuals
to understand individual and societal aging.The urvey of ealth Ageing and etirement
LQXURSH+$LQYROYLQJFRXQWULHV
as of 21 (Austria Belgium Czech epublic
enmark rance ermany reece reland
srael taly the Netherlands oland pain
ZHGHQZLW]HUODQGDQGWKHRUOG+HDOWK
rganization () tudy on global Aing
and adult health (A) in six countries
(China hana ndia exico ussian
ederation and outh Africa) greatly expand
the number of countries by which informative
comparisons can be made of the impact of
policies and interventions on trends in aging
health and retirement. A key aspect of this
new international community of researchers isthat data are shared very soon after collected
with all researchers in all countries.
any other cross-national aging-related
datasets and initiatives offer comparable
demographic indicators that reveal historical
trends and offer projections to help
international organizations and governments
planners and businesses make informed
decisions. These sources include for example
the nternational atabase on Aging involving
227 countries; the nternational Network for
the emographic valuation of opulations
and Their ealth (NT) involving 19
developing nations; the uman ortality
atabase involving 28 countries; and the
26 lobal Burden of isease and isk
actors initiative which is strengthening
the methodological and empirical basis for
undertaking comparative assessments of
health problems and their determinants andconsequences in aging population worldwide.
A Note About the Data Behind This Report
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25
Suggested Resources
Readings
Abegunde athers C Adam T rtegon trong . The burden and costs of chronicdiseases in low-income and middle-income countries. The Lancet 27 (ecember 8); 37:1929-1938.
Avendano lymour Banks ackenbach . ealth disadvantage in adults aged 5 to
74 years: A comparison of the health of rich and poor Americans with that of uropeans. American
Journal of Public Health 29: 99/3:54-548.
%DQV0DUPRW0OGHOG=PLWK'LVHDVHDQGGLVDGYDQWDJHLQWKHQLWHGWDWHVDQGLQ
ngland. JAMA 26 (ay 3); 295/17:237-245.
Chatterji owal athers C Naidoo N erdes mith uzman . The health of aging
populations in China and ndia. Health Affairs 28; 27/4:152-163.Christensen oblhammer au aupel . Ageing populations: The challenges ahead.
The Lancet 29; 374/9696:1196-128.
Crimmins reston Cohen B. eds. International Differences in Mortality at Older Ages.
Dimensions and Sources. ashington C: The National Academies ress 21.
uropean Commission. 2009 Ageing Report: Economic and Budgetary Projections for the
EU-27 Member States (2008-2060). Brussels: uropean Communities 29.
Available at: http://www.da.dk/bilag/publication14992_ageing_report.pdf.
insella e . An Aging World: 2008. ashington C: National nstitute on Aging and ..
Census Bureau 29.
afortune Balestat .Trends in Severe Disability Among Elderly People. Assessing the Evidence
in 12 OECD Countries and the Future Implications. C ealth orking apers 26. aris:
rganization for conomic Cooperation and evelopment 27.
opez A athers C zzati amison T urray C eds. Global Burden of Disease and Risk
Factors. ashington C: The orld Bank roup 26.
National nstitute on Aging. Growing Older in America: The Health and Retirement Study.
ashington C: .. epartment of ealth and uman ervices 27.
xley . Policies for Healthy Ageing: An. Overview. C ealth orking apers 42. aris:rganization for conomic Cooperation and evelopment 29.
lassman B anga isher eeringa eir fstedal B Burke urd
otter odgers teffens C illis and allace B. revalence of dementia in the
nited tates: The aging demographics and memory study. Neuroepidemiology27; 29:125-132.
ohwedder illis . ental retirement. Journal of Economic Perspectives 21 inter; 24/1:
119-138.
eng anan and C. The association of childhood socioeconomic conditions with healthy
longevity at the oldest old ages in China. Demography, 2007; 44/3:497-518.
Suggested Resources
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30/32
26 Global Health and Aging
Web Resources
nglish ongitudinal tudy of Ageing
http://www.ifs.org.uk/elsa/
uropean tatistical ystem (TAT)http://epp.eurostat.ec.europa.eu
ealth and etirement tudy
http://hrsonline.isr.umich.edu/
uman ortality atabase
http://www.mortality.org/
nternational Network on ealth xpectancy and the isability rocess
http://reves.site.ined.fr/en
rganization for conomic Cooperation and evelopment ealth ata 21: tatistics and ndicatorshttp://www.oecd.org/health/healthdata (may require a fee)
urvey of ealth Ageing and etirement in urope
http://www.share-project.org/
nited Nations. World Population Prospects: The 2010 Revision.
http://esa.un.org/unpd/wpp
.. Census Bureau nternational ata Base
http://www.census.gov/ipc/www/idb/
.. National nstitute on Aginghttp://www.nia.nih.gov/
RUOG$O]KHLPHUVHSRUW
http://www.alz.co.uk/research/worldreport/
orld ealth rganization. Projections of Mortality and Burden of Disease, 2004-2030.
http://www.who.int/healthinfo/global_burden_disease/projections/en/index.html.
orld ealth rganization tudy on global Aing and adult health (A)
http://www.who.int/healthinfo/systems/sage/en/
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27
unding for the development of this publication was provided by the ational nstitute on Aging (A), ationalnstitutes of ealth () (2620070099). articipation by the A in support of this publication does not
QHFHVVDULO\UHHFWYLHZVRUSROLFLHVRIWKH1$1+RU'HSDUWPHQWRI+HDOWKDQG+XPDQHUYLFHV
The designations employed and the presentation of the material in this publication do not imply the expression of any
opinion whatsoever on the part of the orld ealth rganization concerning the legal status of any country, territory, city
RUDUHDRURILWVDXWKRULWLHVRUFRQFHUQLQJWKHGHOLPLWDWLRQRILWVIURQWLHUVRUERXQGDULHV'RWWHGOLQHVRQPDSVUHSUHVHQW
approximate border lines for which there may not yet be full agreement.
KHPHQWLRQRIVSHFLFFRPSDQLHVRURIFHUWDLQPDQXIDFWXUHUVSURGXFWVGRHVQRWLPSO\WKDWWKH\DUHHQGRUVHGRU
recommended by the orld ealth rganization in preference to others of a similar nature that are not mentioned.
rrors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
All reasonable precautions have been taken by the orld ealth rganization to verify the information contained in
this publication. owever, the published material is being distributed without warranty of any kind, either expressed or
implied. The responsibility for the interpretation and use of the material lies with the reader. n no event shall the orld
ealth rganization be liable for damages arising from its use.
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National Institute on Aging